Clinical history:

23 year old female with lower abdominal pain.

Diagnostic considerations include:

  • diverticulitis
  • pelvic inflammatory disease (pyosalpinx)
  • ovarian torsion
  • Crohns disease

Treatment for this condition includes:

  • surgical drainage
  • empiric antibiotic therapy
  • ultrasound surveillance
  • TNF inhibitors (Remicade ®)


Pelvic inflammatory disease (PID) is an infection of the upper female genital tract. It arises from an ascending infectious source either from the vagina or cervix. Although many organisms have been implicated, Chlamydia trachomatis and Neisseria gonorrhoeae are the most commonly associated with PID. Sexually active women under the age of 25 years are at the highest risk for developing PID. Although PID is generally easily treated with antibiotics, long term sequelae of this infection include: an increased risk of ectopic pregnancy, tubal occlusion/infertility, and chronic pelvic pain.

Patients can present with pelvic/back pain, fever, nausea, vomiting, and vaginal discharge.

Transvaginal ultrasound is typically the preferred imaging modality. In early PID there may be only subtle findings - these include increased echogenicity of pelvic fat, thickening of the fallopian tube wall and distension of the tube with fluid, as well as enlarged ovaries with indistinct margins. More extensive infections can result in a pyosalpinx; at ultrasound this is manifested by a "cogwheel” appearance to the fallopian tube with marked thickening of the wall and increased wall echogenicity. Additionally, these patients are at risk for developing a tubo-ovarian abscess; ultrasound may show complex, thick walled, cystic adnexal masses which may be uni or multilocular. MR and CT are usually reserved for difficult cases in which it is difficult to differentiate the fallopian tube from complex adnexal masses.

Richard Rupp, MD
University of Pittsburgh School of Medicine, Dept of Radiology


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